Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf

123
Annapoorna Kini
Samin K. Sharma
Editors
Second Edition
Practical Manual
of Interventional
Cardiology

Practical Manual of Interventional
Cardiology

Annapoorna Kini • Samin K. Sharma
Editors
Practical Manual of
Interventional Cardiology
Second Edition

Editors
Annapoorna Kini
Department of Interventional Cardiology
Mount Sinai Hospital
New York, NY
USA
Samin K. Sharma
Department of Interventional Cardiology
Mount Sinai Hospital
New York, NY
USA
ISBN 978-3-030-68537-9 ISBN 978-3-030-68538-6 (eBook)
https://doi.org/10.1007/978-3-030-68538-6
© Springer Nature Switzerland AG 2014, 2021
This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of
the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recita-
tion, broadcasting, reproduction on microfilms or in any other physical way, and transmission or infor-
mation storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar
methodology now known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this publica-
tion does not imply, even in the absence of a specific statement, that such names are exempt from the
relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information in this book
are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the
editors give a warranty, expressed or implied, with respect to the material contained herein or for any
errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional
claims in published maps and institutional affiliations.
This Springer imprint is published by the registered company Springer Nature Switzerland AG
The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland

v
Contents
Part I
Interventional Basics
1 Basics of Radiation Safety�� 3
Gurpreet S. Johal, Reza Masoomi, and Joseph Sweeny
2 Vascular Access�� 11
Gurpreet S. Johal and Nitin Barman
3 Coronary Anatomy and Angiography�� 35
Gurpreet S. Johal, Sunny Goel, and Annapoorna Kini
4 Physiological Assessment During Interventional Procedures�� 51
Tarun Jain and Annapoorna Kini
5 Antiplatelet and Antithrombotic Therapy in Percutaneous
Coronary Interventions �� 61
Amit Hooda, Gurpreet S. Johal, and Usman Baber
6
Patient Selection and Appropriate Use Criteria�� 71
Gurpreet S. Johal and Samin K. Sharma
7 Guide Catheter Selection�� 81
Gurpreet S. Johal, Amit Hooda, and Samin K. Sharma
8 Guidewire Properties and Selection�� 93
Rohit Malhotra, Gurpreet S. Johal, and Samin K. Sharma
9 Fundamentals of Intracoronary Imaging�� 103
Rohit Malhotra, Yuliya Vengrenyuk, and Annapoorna Kini
10 Basics of Intracoronary Devices �� 119
Reza Masoomi, Gurpreet S. Johal, and Annapoorna Kini
11 Hemodynamic Assessment: Right Heart Catheterization,
Pulmonary Hypertension, Left-to-Right Shunt, Constriction,
and Restriction �� 143
Tarun Jain, Annapoorna Kini, and Matthew Tomey

vi
12 Hemodynamic Assessment of Valvular Stenosis and
Regurgitation�� 155
Reza Masoomi, Gurpreet S. Johal, and Annapoorna Kini
13
Vascular Closure Devices and Complications �� 167
Reza Masoomi and Sahil Khera
Part II
Coronary Intervention
14 Basics of Intervention�� 189
Tarun Jain and Annapoorna Kini
15 Difficult Stent Delivery�� 199
Amit Hooda and Annapoorna Kini
16 Bifurcation Lesions�� 209
Sunny Goel, Gurpreet S. Johal, and Annapoorna Kini
17 Ostial Lesion Interventions �� 219
Radha Mehta and Annapoorna Kini
18 Left Main Coronary Interventions�� 227
Radha Mehta and Samin K. Sharma
19 Chronic Total Occlusions�� 241
Lorenzo Azzalini, Gurpreet S. Johal, and Annapoorna Kini
20
Acute Coronary Syndrome: STEMI and
Non-STEMI Interventions�� 259
Amit Hooda and Joseph Sweeny
21 Coronary Artery Bypass Graft Interventions �� 267
Hemal Bhatt and Samin K. Sharma
22
Severely Calcific Coronary Artery Lesion Interventions �� 275
Raman Sharma and Samin K. Sharma
23 Transradial Coronary Interventions�� 293
Tarun Jain and Nitin Barman
24
Coronary Complications and Management of
Percutaneous Coronary Interventions �� 303
Raman Sharma, Samin K. Sharma, and Annapoorna Kini
Part III
Special Procedures
25 Contrast-Induced Nephropathy Post Percutaneous
Interventional Procedures�� 321
Hemal Bhatt, Lorenzo Azzalini, and Samin K. Sharma
26 Intracoronary Stent Restenosis�� 327
Keisuke Yasumura, Annapoorna Kini, and Samin K. Sharma
Contents

vii
27 Advanced Hemodynamic Support�� 335
Hemal Bhatt, Gurpreet S. Johal, and Gregory Serrao
28 Aortic Valve Interventions: Balloon Aortic Valvuloplasty and
Transcatheter Aortic Valve Replacement�� 371
Parasuram Krishnamoorthy, Nagendra Boopathy Senguttuvan,
Samin K. Sharma, and Annapoorna Kini
29
Guide Catheter Selection in Patients with Transcatheter
Aortic Valve Replacement �� 403
Sunny Goel, Annapoorna Kini, and Samin K. Sharma
30 Percutaneous Transvenous Mitral Commissurotomy�� 413
Nagendra Boopathy Senguttuvan, Gurpreet S. Johal,
Samin K. Sharma, and Annapoorna Kini
31
Transcatheter Edge to Edge Mitral Valve Repair�� 423
Nagendra Boopathy Senguttuvan, Parasuram Krishnamoorthy,
Gilbert H. L. Tang, and Annapoorna Kini
32 Alcohol Septal Ablation�� 435
Parasuram Krishnamoorthy, Gurpreet S. Johal, and Annapoorna Kini
33 Pericardiocentesis and Balloon Pericardiotomy �� 441
Gurpreet S. Johal, Amit Hooda, Reza Masoomi,
and Annapoorna Kini
Index�� 451
Contents

3
© Springer Nature Switzerland AG 2021
A. Kini, S. K. Sharma (eds.), Practical Manual of Interventional Cardiology,
https://doi.org/10.1007/978-3-030-68538-6_1
Basics of Radiation Safety
Gurpreet S. Johal, Reza Masoomi, and Joseph Sweeny
Introduction
Cardiac catheterization laboratories use X-ray radiation to perform various car-
diac procedures. The X-ray beam is emitted from the tube below the catheteriza-
tion table. X-rays are composed of photons of different energies, and those which
have abundant energy to disrupt the cellular structure or genetic makeup of an
individual cell are characterized as ionizing radiation. A biomolecule can be
altered by reacting with radiation-generated free radicals or by being directly ion-
ized by radiation [1].
More than 95% to 99% of the X-ray energy that enters the patient is either
absorbed or scattered within the patient [1]. The remaining 1% to 5% of the incident
X-ray penetrates the subject, reaching the image detector to form the image or scat-
tered to nearby medical personnel [1]. The risk of radiation injury is of particular
concern for physicians who perform invasive cardiovascular procedures, as they are
the most highly exposed healthcare workers [1].
Often, focus on procedure complexity dominates the importance of personal and
patient radiation protection. More complex procedures such as percutaneous inter-
ventions of chronic total occlusions and structural heart diseases are being per-
formed, leading to longer procedure times and radiation exposure [2]. Fortunately,
technological advances have improved image quality while utilizing lower doses of
X-ray radiation [2]. Still, it is imperative to emphasize personal and preventative
strategies to minimize radiation exposure, as the dangers of repeated radiation expo-
sure are serious, but not obvious.
G. S. Johal (*) · R. Masoomi · J. Sweeny
Department of Interventional Cardiology, Mount Sinai Hospital, New York, NY, USA
e-mail: Gurpreet.Johal@mountsinai.org; Reza.Masoomi@mountsinai.org;
joseph.sweeny@mountsinai.org
1

4
Biological Effects
The biological effects of radiation are classified as either tissue reactions (formerly
called deterministic effects) or stochastic effects (also known as probabilistic
effects) (Table 1.1) [3]. Tissue reactions occur if the radiation-induced injury to a
cell exceeds its ability to repair itself and maintain function [1]. Tissue reactions are
dose-dependent and become macroscopically apparent once a threshold radiation
dose is exceeded [1]. Subsequent larger doses of ionizing radiation lead to more
extensive injury in a dose-related manner, as more cells are affected [1]. Subthreshold
doses may also cause cellular injury and death but the injury is not evident because
an insignificant number of cells are involved [1].
Skin injury is the most common tissue reaction seen with X-ray fluoroscopy expo-
sure. Skin injuries typically occur at the site of the X-ray beam entrance (usually the
patient’s back) and take on the rectangular shape of the X-ray beam [1]. These inju-
ries vary in severity from erythema to desquamation, ulceration, and necrosis [1].
Other tissue reactions include cataract formation, bone necrosis, fetal organogenesis,
and cardiac defects including damage to the myocardium, cardiac valves, and coro-
nary arteries [1]. Tissue reactions usually occur days to months following radiation
exposure, as it takes time for molecular damage to evolve and cause sufficient cel-
lular dysfunction that later manifests at the macroscopic level [1, 3].
Stochastic effects result from radiation-induced damage of a cell’s genetic mate-
rial, deoxyribonucleic acid (DNA), with the cell surviving the intrinsic repair pro-
cess [3]. Unlike tissue reactions, stochastic effects are not known to have a dose
threshold, and the severity of an injury is not dose-related [1]. Rather, the probabil-
ity of a stochastic event is thought to increase approximately linearly [1]. These
relationships are the foundation for the “linear-no threshold” theory and the basis
for ALARA “As Low As Reasonably Achievable” principle. Theoretically, a single
X-ray photon ionizing a strategic atom within a portion of DNA that encodes a criti-
cal gene could develop into a concerning malignancy, and this is the reason why
radiation exposure should always be minimized [1]. Stochastic effects typically
Table 1.1 Biological effects of ionizing radiation
Tissue reactions “Deterministic” Chance damage “Stochastic”
Dose level Medium to high Low
Latency period Short (days or weeks) Long (years)
Threshold dose Yes (the level at which effects
begin to appear is known)
Probably no threshold exists, but some
uncertainty. The chance of developing
a disease is directly proportional to the
amount of radiation exposure.
Biological
mechanism
Predominantly cell death Cell damage
Sample clinical
effects
Skin injury, cataract, hair loss,
sterility
Cancer, hereditary disorders, inherited
defect in offspring
Adapted from Picano et al. [3]
G. S. Johal et al.

5
occur after a period of latency of several years, and the likelihood an effect will
occur is further influenced by several factors including a person’s age, gender,
genetics, and many environmental factors including background radiation [1, 3].
For every 100 patients exposed to 100 mSv of radiation, one is at risk of developing
a solid malignancy or hematological malignancy [4].
Regulatory Recommendations
The Society for Cardiac Angiography and Intervention outlines the basic principles
for radiation safety and protection in the cardiac catheterization laboratory.
• Radiation-induced biological effects are the result of random statistical probabil-
ity for low radiation doses. The probability of these effects is directly propor-
tional to the radiation dose received.
• Since radiation-induced biological effects are random, and no threshold dose
exists for these effects, even a small dose could potentially induce biological
effects; therefore, no level of radiation exposure can be considered com-
pletely safe.
• Radiation exposure is cumulative and there is no washout phenomenon as with
other toxin exposures.
• Each person involved in the cardiac catheterization laboratory has accepted a
certain degree of risk posed by radiation exposure.
The National Council on Radiation Protection (NCRP) and the International
Commission on Radiological Protection (ICRP) are regulatory bodies from the
United States and Europe. They recommend healthcare workers not receive occupa-
tional radiation exposure higher than the dose limits published, with standards set
forth by the ICRP being more stringent [1]. There are two types of occupational
dose limits in the NCRP and ICRP recommendations. The first provides occupa-
tional dose limits for specific organs or tissues, and is expressed as an equivalent
dose for deterministic effects involving an organ or tissue [5]. The second estab-
lishes an acceptable risk level for cancer induction, and is expressed as an effective
dose for stochastic effects throughout the body [5]. An effective dose is intended to
be proportional to the risk of radiation-induced cancer [5]. In the United States, the
Occupational Safety and Health Administration and state regulations provide spe-
cific requirements for personal dosimetry when using X-rays [5]. Current regulatory
considerations for radiation dose limits are listed in Table 1.2.
Pregnancy does not preclude one from working in an area of occupational radia-
tion exposure [5]. However, additional restrictions and safety measures should be
taken to reduce occupational exposure of the patient and developing fetus than those
detailed in Table 1.2 [5]. Once a worker has voluntarily declared her pregnancy, the
ICRP recommends an additional dose to the conceptus does not exceed more than
1 mSv during the remainder of the pregnancy [5]. The NCRP in this situation rec-
ommends a 0.5 mSv equivalent dose monthly limit for the conceptus (excluding
1 Basics of Radiation Safety

6
medical and natural background radiation) [5]. Moreover, workers in the United
States who do not wish to declare their pregnancy are not required to do so [5].
ALARA
ALARA, which stands for “As Low As Reasonably Achievable,” is the fundamental
radiation safety principle and unifying goal of radiation safety programs. All opera-
tors are to follow protocols to minimize the use of radiation while performing pro-
cedures and adhere to ALARA limits as detailed in Table 1.2. If the radiation
exposure exceeds the limit, the radiation safety officer at a given facility is expected
to review the individual case. The focus of the review is to determine the reason for
high radiation exposure and improve safety procedures to minimize excessive expo-
sure to radiation in the future. Three principles help in maintainingALARA practice:
• Time: Reducing the duration of radiation exposure will reduce the dose.
• Distance: Radiation follows the inverse square law. Doubling the distance from
the source will reduce radiation exposure by a factor of four.
• Shielding: Using absorbent material like lead for X-rays reduces exposure.

Radiation Units and Dose Monitoring
Patient exposure to radiation must be documented and is measured as Air Kerma
(Kinetic Energy Released in MAtter) and dose area product (DAP) [6]. Air Kerma
is the amount of kinetic energy delivered to air and is measured 15 cm towards the
Table 1.2 Current regulatory considerations for radiation dose limits
Tissue Risk
Recommended maximum dose
NCRP ICRP
Whole body Stochastic 50 mSv/year 20 mSv/year, averaged
over defined periods of 5
years, with no single year
exceeding 50 mSv
Lens of the eye Deterministic 150 mSv/year 20 mSv/year, averaged over
defined periods of 5 years,
with no single year exceeding
50 mSv
Extremities (hands
and feet), skin or
individual organ
Deterministic 500 mSv/year 500 mSv/year (for skin:
averaged over 1 cm² of skin
regardless of the area
exposed)
Embryo-fetus Deterministic 5 mSv/entire pregnancy,
and not to exceed
0.5 mSv/month
1 mSv/remainder of the
pregnancy once declared
General public Stochastic 1 mSv/year 1 mSv/year
National Council on Radiation Protection and Measurements (NCRP)
International Commission on Radiological Protection (ICRP)
10 mSv = 1 rem
Adapted from Miller et al. [5]
G. S. Johal et al.

7
x-ray tube side of the isocenter, the point where the primary x-ray beam intersects
with the rotational axis of the C-arm gantry [6]. Air Kerma has been associated with
the deterministic effects of radiation. DAP, is also referred to as Air Kerma Area
Product, is the product of Air Kerma and the x-ray radiation field area [6]. It is mea-
sured in Gray·cm2 and is thought to correlate with the stochastic effects of radiation
[6]. Refer to Table 1.3 for the description of radiation units for dose monitoring.
Operator exposure is expressed as an equivalent dose for organ-specific exposure
and an effective dose for whole-body exposure [6]. The effective dose represents the
sum of equivalent doses from different tissues, adjusted to the radiation sensitivity
of each tissue [6]. The effective dose can be estimated by multiplying the average
equivalent dose in each exposed tissue by a tissue weighting factor and summing
these values over the whole body.
Safety Components
During cardiac catheterization, patients could receive a radiation dose on average of
8–10 mSv and this increases significantly with more complex procedures. Protective
equipment, if worn correctly, prevents absorption of nearly 95% of scatter radiation,
and operators receive an average effective dose of 0.2 to 100 microsieverts (μSv)
per procedure with a per-procedure average of 8 to 10 (μSv) [1, 4]. Therefore, an
interventional cardiologist who performs around 500 procedures/year will receive,
in addition to background exposure, a cumulative dose of nearly 10 mSv/year, and
in most extreme situations, approximately 300 mSv over an active 30-year career
[1]; a projected professional lifetime attributable excess cancer risk of 1 in 100 [3].
If an operator receives a high occupational radiation dose, an investigation must
be performed. This occurs if the total effective dose an operator receives is 0.5 mSv/
month, lens equivalent dose 5 mSv/month, or extremity equivalent dose 15 mSv/
month [6]. The first step in the investigation of a high (or unusually low) value is to
confirm the validity of the dosimeter reading. If dosimeter reading is considered to
be accurate, the next step in the investigative process is to have a trained physicist
Table 1.3 Description of radiation units for dose monitoring
Description
Fluoroscopic time Total time of fluoroscopy used during a procedure. This does not include
the total time of cine imaging. As a result, this parameter underestimates
the total radiation dose delivered to a patient. It is recorded in minutes
(min)
Air Kerma (AK) Refers to X-ray energy delivered to air at the interventional reference
point. It is the amount of energy released by the interaction of the
radiation with a unit mass of air. It is a measure of radiation exposure
which correlates with the risk of deterministic effects. It is recorded in
Grays (Gy)
Dose area product
(DAP)/Air
Kerma-area product
Product of total radiation dose and area of the X-ray field. It is a measure
of radiation exposure which correlates with the risk of stochastic effects.
It is recorded in Gy.cm2

8
or experienced colleague observe the operators’ work habits with close monitoring
of equipment settings, operator positioning relative to the radiation source, and use
of personal protective equipment [6].
Radiation Monitoring
• Personal dosimetry monitors are the gold standard for radiation surveillance and
are required to be used by all health care providers who are employed in areas
where radiation is being utilized [6].
• There are two options for measuring effective dose equivalent for workers who
use lead aprons.
–
– The first option is to have one badge on the thyroid collar outside the apron
and the other badge under the apron at the waist level [1, 6].
–
– The second option is to use only one badge outside the lead apron on the thy-
roid collar [1, 6].
• Eye dose can be measured with a dedicated lens eye dosimeter, which gives the
most accurate measurement when placed on the side of the head closer to the
eye [6].
Shielding
• Lead garments to protect the gonads and approximately 80% of the bone marrow.
–
– 0.5 mm lead apron stops approximately 95% of the scatter radiation [7].
• Separate thyroid collars, especially for the young and in those whose radiation
dose exceeds 4 mSv/month [7].
• 0.25 mm lead eyeglasses for eye protection (radiation can cause posterior sub-
capsular cataracts).
• Use of below the table-mounted shields.
• Transparent ceiling-mounted shields.
• Disposable radiation-absorbing sterile drapes.
• Proper maintenance and periodic inspection (at least once a year) of lead aprons.
Procedural Issues
• Precautions to minimize exposure to patient and operator.
• Utilize radiation only when imaging is necessary to support clinical care.
• Minimize the use of cine angiography.
• Minimize the use of steep angles of the X-ray beam. Left anterior oblique cranial
angulation has the highest degree of scatter radiation exposure to the operator.
• Minimize the use of magnification modes.
• Minimize the frame rate of fluoroscopy and cine.
G. S. Johal et al.

9
• Keep the image intensifier close to the patient.
• Utilize collimation to the fullest extent possible.
• Monitor radiation dose in real-time.

Precautions to Minimize Operator Exposure
• Use and maintain appropriate protective garments.
• Maximize distance of the operator from the X-ray source and patient.
• Keep above and below table shields in the proper position at all times.
• Keep all body parts out of the field of view.

Precautions to Minimize Patient Exposure
• Keep table height as high as comfortable for the operator.
• The height of the table can significantly affect the scatter radiation. The patient
should be placed away from the radiation source (ideally 70 cm away) and close
to the image intensifier as much as possible [6].
• Vary the imaging beam angle to minimize exposure to any one-skin area.
• Minimizing steep LAO and anteroposterior cranial angles.
• Fluoroscopy dose is more sensitive to angulation changes compared with acqui-
sition dose likely due to higher tissue-based attenuation of the lower-dose fluo-
roscopy X-ray beam in angulated projections [6].
• Keep the patient’s extremities out of the beam.

Impact on Patient Care
Inclusion of radiation dose on cardiac catheterization reports is mandatory and it
helps identify which patients need appropriate follow-up for possible radiation-
related tissue injury postoperatively. Follow-up should be based on the radiation
dose level as detailed below [7]:
• AK 5 Gy:
–
– Patient education regarding potential skin changes like redness and report
if seen.
–
– The patient to be contacted within 30 days post-procedure.
• AK 10 Gy:
–
– Qualified physicist to perform detailed analysis and calculate peak skin dose.
–
– Office visit in 2–4 weeks with skin examination.
• Peak Skin Dose (PSD) 15 Gy:
–
– Contact hospital risk management.
–
– Notification to regulatory agencies.

10
Accordingly to the Society of Interventional Radiology, documentation of over-
exposure is also advised if DAP radiation exceeds 500 Gy.cm2, or fluoroscopy time
is 60 minutes [6]. If a radiation-related tissue injury develops during the follow-up
period, the patient should be referred to an experienced provider dealing with such
complications. In most circumstances, a skin biopsy should not be performed.
References
1. Writing Committee Members, Hirshfeld JW Jr, Ferrari VA, Bengel FM, Bergersen L,
Chambers CE, Einstein AJ, Eisenberg MJ, Fogel MA, Gerber TC, Haines DE, Laskey WK,
Limacher MC, Nichols KJ, Pryma DA, Raff GL, Rubin GD, Smith D, Stillman AE, Thomas
SA, Tsai TT, Wagner LK, Samuel Wann L; ACC Task Force on Expert Consensus Decision
Pathways, Januzzi JL Jr, Afonso LC, Everett B, Hernandez AF, Hucker W, Jneid H, Kumbhani
D, Edward Marine J, Morris PB, Piana RN, Watson KE, Wiggins BS. 2018 ACC/HRS/NASCI/
SCAI/SCCT Expert Consensus document on optimal use of ionizing radiation in cardiovascu-
lar imaging-best practices for safety and effectiveness, part 1: radiation physics and radiation
biology: a report of the American College of Cardiology Task Force on Expert Consensus
Decision Pathways developed in collaboration with mended hearts. Catheter Cardiovasc Interv.
2018 Aug 1;92(2):203–221. https://doi.org/10.1002/ccd.27660. Epub 2018 Aug 29. Review.
2. Kumar G, et al. Radiation safety for the interventional cardiologist—a practical approach to pro-
tecting ourselves from the dangers of ionizing radiation.American College of Cardiology Latest
in Cardiology. 2016. https://www.acc.org/latest-in-cardiology/articles/2015/12/31/10/12/
radiation-safety-for-the-interventional-cardiologist.
3. Picano E, Vañó E, Rehani MM, Cuocolo A, Mont L, Bodi V, Bar O, Maccia C, Pierard L,
Sicari R, Plein S, Mahrholdt H, Lancellotti P, Knuuti J, Heidbuchel H, Di Mario C, Badano
LP. The appropriate and justified use of medical radiation in cardiovascular imaging: a position
document of the ESC Associations of Cardiovascular Imaging, Percutaneous Cardiovascular
Interventions, and Electrophysiology. Eur Heart J. 2014 Mar;35(10):665–72. https://doi.
org/10.1093/eurheartj/eht394. Epub 2014 Jan 8. Review.
4. Al Kharji S, Connell T, Bernier M, Eisenberg MJ. Ionizing radiation in interventional cardiol-
ogy and electrophysiology. Can J Cardiol 2019 Apr;35(4):535–538. https://doi.org/10.1016/j.
cjca.2019.01.006. Epub 2019 Jan 25.
5. Miller DL, Schueler BA, Balter S. National Council on radiation protection and measurements;
international commission on radiological protection. New recommendations for occupational
radiation protection. J Am Coll Radiol. 2012 May;9(5):366–8. https://doi.org/10.1016/j.
jacr.2012.02.006.
6. Christopoulos G, Makke L, Christakopoulos G, Kotsia A, Rangan BV, Roesle M, Haagen D,
Kumbhani DJ, Chambers CE, Kapadia S, Mahmud E, Banerjee S, Brilakis ES. Optimizing
radiation safety in the cardiac catheterization laboratory: a practical approach. Catheter
Cardiovasc Interv. 2016 Feb 1;87(2):291–301. https://doi.org/10.1002/ccd.25959. Epub 2015
Nov 3. Review.
7. Chambers et al. Radiation safety program for the cardiac catheterization laboratory. Catheter
Cardiovasc Interv. 2011;77(4):546–56. https://doi.org/10.1002/ccd.22867.
G. S. Johal et al.

11
https://doi.org/10.1007/978-3-030-68538-6_2
Vascular Access
Gurpreet S. Johal and Nitin Barman
Introduction
Over the past decade, the use of a transradial approach (TRA) to obtain arterial
access for cardiac catheterization procedures has gained popularity and surpassed
the use of a femoral artery approach (FA) [1, 2]. The brachial artery, axillary artery,
ulnar artery, and femoral artery cut down for access are rarely used.
Femoral Access
Obtaining femoral artery access is crucial for procedural and clinical success, and
remains one of the key technical challenges for an interventional cardiologist.
Access site complications are an important cause of cardiac catheterization morbid-
ity and mortality.
• A “high” sheath insertion above the inguinal ligament increases the risk of retro-
peritoneal bleeding.
• A “low” sheath insertion into the profunda femoris or the superficial femoral
artery (SFA) may result in an arteriovenous fistula, pseudoaneurysm, or limb
ischemia.
G. S. Johal (*) · N. Barman
e-mail: Gurpreet.Johal@mountsinai.org; nitin.barman@mountsinai.org
2

12

Contraindications for Femoral Artery Access
• Recommend not to perform if INR ≥2.0.
• If a patient is taking warfarin (INR ≥2.0) and a percutaneous procedure needs to
be performed urgently or emergently via a FA, 1–2 units of fresh frozen plasma
should be given to correct the coagulopathy. Patients who are considered high-
risk for thromboembolic events should be bridged with unfractionated heparin or
low molecular weight heparin.
• Avoid in patients taking a factor Xa inhibitor (rivaroxaban, apixaban) or a direct
thrombin inhibitor (dabigatran), unless these medications have been held for
24–48 hr [3].
• Avoid in patients with morbid obesity, severe peripheral vascular disease, or aor-
tic dissection.
Sheath Selection
• A 5 French (Fr) sheath will suffice for most diagnostic cardiac procedures.
–
– If the pretest probability of disease is low, consider using a 4 Fr sheath.
–
– Common femoral artery (CFA) diameter in women and diabetics tends to be
smaller; consider using a 4 Fr sheath [4].
• The sheath can be upsized as needed for interventions (Table 2.1).
Table 2.1 Femoral sheath size by the procedure
Procedure
Sheath
size
Diagnostic cardiac catheterization 5 Fr
PCI— most PCIs, two-stent strategy for bifurcation lesions [DK Crush technique,
Culotte technique], bailout stent technique [TAP technique, Reverse Crush (internal)
technique], orbital atherectomy or rotational atherectomy burr 2 mm
6 Fr
PCI with a planned two-stent strategy for bifurcation lesions [Mini Crush
technique, modified T technique, SKS technique, V technique] or rotational
atherectomy burr of 2 mm
7 Fr
Rotational atherectomy burr of 2.15 mm or 2.25 mm 8 Fr
Balloon aortic valvuloplasty Tyshak 16–20 mm
balloon
8 Fr
Vida 16–20 mm balloon 8 Fr
Z-MED 20 mm balloon 10 Fr
True 20 mm balloon 12 Fr
Impella 2.5 13 Fr
CP 14 Fr
Transcatheter aortic valve replacement SAPIEN 3 (23 mm,
26 mm)
SAPIEN 3 (29 mm)
Evolute Pro Plus (23 mm,
26 mm, 29 mm)
Evolute Pro Plus
(34 mm)
14 Fr
16 Fr
18 Fr
22 Fr
G. S. Johal and N. Barman

13
Needle Used
• High-risk patients may require the use of a micropuncture needle for more con-
trolled access into the CFA, so a vascular closure device may be employed to
close the access site after the procedure. These patients include:
–
– Extremely obese patients with deep vasculature.
–
– Patients who are anticoagulated or have a coagulopathy.
–
– Patients with known or suspected peripheral arterial disease (arterial
access should be obtained in a relatively non-diseased segment of the vessel).

Ideal Access Location
• The segment of the common femoral artery below the inguinal ligament (1–2 cm
below the line traced from the anterior superior iliac spine to the pubic tubercle)
is the ideal location for arterial access.
• This correlates roughly to an area that is at the mid-third of the femoral head,
which is usually above the femoral bifurcation and below the lowest point of the
course of the inferior epigastric artery (Fig. 2.1).
Pearls
• In obese patients, stretch the skin tightly over the femoral head by moving
the pannus out of the way and taping it across the body.
• Use long sheaths (25 cm or 45 cm) in patients with tortuous iliac arteries
or when the CFA is located deep below the subcutaneous tissue.
Anterior spine
Skin crease
Inguinal
ligament
Common
femoral
artery
Profunda
Superficial
femoral
artery Femoral vein
Saphenous vein
Pubic tubercle
2 cm
below (mid
femoral
head) Common
Femoral Artery
Inferior
Epigastric
Artery
Superficial
Femoral
Artery
Profunda
Fig. 2.1 Location and anatomy for femoral access
2 Vascular Access

14
• The ultrasound (US) guided approach is safe and effective. US use to cannulate
the CFA reduces the number of attempts, the time required to achieve success-
ful access, and the rate of vascular complications [5].
• Femoral artery bifurcation is below the inferior border of the femoral head in
80% of cases, and below the inguinal ligament and middle of the femoral head in
all patients [1].
• The femoral artery lies on the medial third of the femoral head in 92% of patients,
and is completely medial to the femoral head in 8% of patients [6–8].

Common Steps for Micropuncture and Regular Access Needle
• Fluoro the femoral head with an overlying hemostat to mark the inferior border
of the femoral head and palpate the point of maximal pulsation at this level.
• Give lidocaine 1–2% subcutaneously. Create a subcutaneous wheal at the entry
site with 5 cc of lidocaine and then gradually deliver an additional 10–15 cc of
local anesthetic to the deeper subcutaneous tissue, covering the anticipated nee-
dle path from the skin to the arterial wall.
• The needle entry point at the skin level should be at the lower border of the femo-
ral head. Aim for an area between the inferior border of the femoral head to the
mid femoral head (Fig. 2.1).
–
– Monitor the patient for any vagal reaction, and the ECG for bradycardia.
• In rare cases, a small skin nick followed by the opening of the subcutaneous
space gently with blunt forceps is required.
–
– This provides a pathway for blood to ooze out of the skin in case of bleeding
and allows for early identification of complications.
–
– This step should be considered when there is difficulty inserting a sheath or
when Perclose™ technique of closure is planned, especially for the closure of
large sheaths.
• Enter the anterior wall of the femoral artery by advancing either the 18-gauge
needle or the 21-gauge micropuncture needle at a 45° angle until there is back-
flow of arterial blood at the needle hub (Fig. 2.2. Step Ia).
–
– Advancing the needle at a more vertical angle can result in kinking of the
sheath and a more horizontal angle can result in a high stick.
Pearls
• The inguinal crease is not a reliable landmark; however, we find it safer to
puncture below it [9].

15
–
– The backflow of blood when an 18-gauge needle is used should be brisk and
pulsatile.
–
– The flow through a micropuncture needle is six times less compared with
blood flow through an 18-gauge needle. The backflow may not appear pulsa-
tile, but should be steady.

18-gauge Needle Steps
• The 0.035″ guidewire is threaded through the needle. There should be no resis-
tance as the guidewire is advanced. If resistance is encountered, fluoroscopy
should be used to ensure guidewire advancement is correct (Fig. 2.2. Step II a,
b, and c).
Step I
a Insert needle into
artery at a 45
degree angle
Step II-Regular access needle
a Insert 0.035 guidewire
through needle
b Check fluoroscopic
point of entry
c Remove needle
d Pass catheter over wire e Remove wire
Fig. 2.2 Steps of femoral access
2 Vascular Access

16
• Next, the needle is removed, the sheath/dilator system is advanced over the guide-
wire until the unit is well within the lumen of the vessel, and the guidewire and
dilator are removed, leaving the sheath within the artery. (Fig. 2.2. Step II d and e).
• Once arterial access is obtained, a femoral arteriogram should be obtained by
injecting dye through the sheath.
Micropuncture Steps
• Access the artery as described above using the needle from the micropuncture
access kit.
• Once arterial access is obtained, the accompanying 0.018″ guidewire is advanced
through the needle (Fig. 2.2. Step III a). Because the wire is straight (not J-tipped),
Step III-Micropuncture access
a Insert 0.018 guidewire
through micropuncture
needle
d Reintroduce 0.018
guidewire and remove
2 Fr dilator and
insert 4 Fr dilator
catheter
g Remove guidewire
e Insert 0.035 guidewire
through 4 Fr catheter
f Pass 5 Fr catheter over
the guidewire
b Check fluoroscopic
point of entry
c Remove needle and insert
a 2 Fr dilator over wire
and confirm position
using contrast
Fig. 2.2 (continued)

17
it is essential to check by fluoroscopy that the wire tip is in the iliac artery and
has not advanced into a small branch (Fig. 2.2. Step III b).
• Remove the needle, thread the 2 Fr dilator accompanying the 4 Fr sheath/dilator
system over the guidewire into the artery (Fig. 2.2. Step III c), and remove the
guidewire. Alternatively, the 4 Fr micropuncture sheath/dilator system can be
inserted directly over the guidewire. The 2 Fr dilator and guidewire is
removed, leaving the 4 Fr micropuncture sheath within the artery.
• Perform an arteriogram with a 3–5 cc injection of contrast through the 2 Fr dila-
tor to confirm the site of entry. If the arterial puncture site is not optimal, remove
the catheter, hold pressure for 3–5 min to achieve hemostasis, and re-access the
artery with the micropuncture needle. If the 4 Fr microcatheter was used to inject
contrast and access is acceptable, insert the 0.035 guidewire and follow the
steps as detailed below.
• Reinsert the 0.018 guidewire, remove the 2 Fr dilator and re-assemble the 4 Fr
micropuncture sheath/dilator system, advance the system over the guidewire until
the unit is well within the lumen of the vessel, remove the guidewire and dilator,
and leave the sheath within the artery (Fig. 2.2. Step III d).
• Exchange the 0.018″ wire with a 0.035″ guidewire, remove the 4 Fr sheath,
advance the 5 Fr or 6 Fr sheath/dilator system over the 0.035 guidewire, remove
the guidewire and dilator, and leave the sheath within the artery (Fig. 2.2. Step III
e, f, and g).
Angiographic Views
• The common femoral artery bifurcation is usually best visualized in the ipsilat-
eral view 30°.
• In some cases, a contralateral view with a slight caudal projection may allow
better visualization of the bifurcation.
• The angiogram should be evaluated carefully to see the level of puncture and the
presence of arterial dissection or extravasation of dye due to peri-sheath leak,
perforation, or back wall puncture.
Complications
• Clinical features, prevention, and treatment of various femoral artery complica-
tions are listed in Table 2.2 [2].
2 Vascular Access

18
Table
2.2
Complications
of
femoral
access:
clinical
features,
prevention,
and
treatment
Type
Clinical
features
Prevention
Treatment
Hematoma
Incidence:
5–23%
Pain,
swelling,
or
hardened
area
under
the
skin
at
the
site
If
severe
can
cause
tachycardia,
hypotension,
and
fall
in
Hct
Most
resolve
in
a
few
weeks
Adequate
compression
after
sheath
removal
Avoid
arterial
puncture
below
the
femoral
bifurcation
Manual
pressure
Mark
the
area
to
monitor
change
in
size
Obtain
a
vascular
ultrasound
to
evaluate
for
pseudoaneurysm
Other
steps
same
as
for
retroperitoneal
hematoma
Pseudoaneurysm
Incidence:
0.5–9%
Swelling
at
the
insertion
site
Large,
painful
pulsatile
mass
Bruit
and/or
thrill
in
the
groin
area
A
pseudoaneurysm
can
rupture
or
cause
nerve
compression
resulting
in
limb
weakness
Diagnosed
by
ultrasound
Adequate
compression
after
sheath
removal
and
good
hemostasis
Avoid
arterial
puncture
below
the
femoral
bifurcation
Bed
rest
Small:
Monitor
as
they
spontaneously
resolve
after
cessation
of
anticoagulation
Large:
manual
or
ultrasound-guided
compression/thrombin
injection
or
surgery
Arteriovenous
fistula
Incidence:
0.2–2.1%
Bruit
±
thrill
at
the
access
site
Extremity
swelling,
tenderness
Diagnosed
by
ultrasound
Adequate
compression
after
sheath
removal
and
good
hemostasis
Avoid
arterial
puncture
below
the
femoral
bifurcation
or
above
the
inguinal
ligament
Some
resolve
spontaneously
Ultrasound-guided
compression
Surgical
repair
Infection
Incidence
~
0.4%
80%
are
diabetics
with
a
mortality
rate
of
6%
50%
~
mycotic
aneurysm,
50%
result
in
mycotic
aneurysm
with
S.
aureus
in
75%
of
cases
S.
aureus
in
75%
of
cases
The
incubation
period
is
1
week
to
1
month.
Have
a
high
degree
of
suspicion
for
any
pain,
erythema,
swelling,
drainage
from
the
puncture
site,
or
systemic
signs
of
infection
up
to
1-month
post-procedure,
especially
in
diabetics
VCD/manual
sheath
removal
protocol
Clean
area
with
an
antiseptic
solution.
Place
sterile
towels
and
change
gloves.
Pull
out
in
one
fluid
movement
and
let
it
bleed
back
and
hold
pressure
just
above
the
puncture
site.
Do
not
rub
into
the
wound
Avoid
VCD
in
patients
with
significant
PVD,
CFA
5
mm,
3
prior
procedures
at
the
same
site,
or
if
the
puncture
is
below
the
femoral
bifurcation.
Give
1
g
of
IV
Cefazolin
or
1
g
of
IV
vancomycin
(PCN
allergic
patients)
in
DM
or
morbidly
obese
patients
receiving
VCD
Long-term
IV
antibiotics
or
antifungals
Surgical
debridement
and
removal

19
Retroperitoneal
hematoma
Incidence:
0.15–0.4%
Moderate
to
severe
abdominal,
back,
or
ipsilateral
flank
pain
Groin/hip
pain
with
radiation
to
back
if
close
to
the
iliopsoas
muscle
especially
during
extension
of
the
hip
Hypotension
and
tachycardia.
Ecchymosis
and
decrease
in
hematocrit
are
late
signs
Diagnosed
by
CT
Potentially
fatal
if
not
recognized
early
Avoid
puncture
above
the
inguinal
ligament
Use
micropuncture
access
in
obese
patients
or
difficult
access
and
confirm
site
before
sheath
insertion
Adequate
compression
after
sheath
removal
and
good
hemostasis
Do
not
delay
treatment
if
suspicion
is
high
IVF/bed
rest
Interrupt
anticoagulants
and
antiplatelets
with
blood
transfusion
if
required
May
need
surgical
evacuation/
percutaneous
balloon
tamponade
Arterial
occlusion
by
thrombo-embolism
(TE)
Incidence:
0.8%
5
Ps:
pain,
paralysis,
pallor,
paresthesias,
pulselessness
Doppler
studies/angiogram
Anticoagulation
Vasodilators
Careful
monitoring
during
sheath
removal
and
injection
Small
TE
may
undergo
spontaneous
lysis
Larger
TE
may
need
surgical
or
percutaneous
thromboembolectomy
or
thrombolytic
agents
Percutaneous
thrombectomy:
Access
from
the
contralateral
side
and
give
5000
units
of
heparin
if
no
Anticoagulated
Cross
TE
with
a
0.014″
or
0.018″
wire
Thrombectomy
device
is
then
introduced
over
the
wire
to
remove
any
thrombi
±
PTA/stent
Iliac
dissection
Usually
painless
and
retrograde
Bed
rest
with
follow-up
clinical
exams
and
imaging
if
nonflow
limiting
If
flow
limiting,
PTCA
+
stent
is
the
treatment
of
choice
Femoral
neuropathy
Incidence:
~0.2%
Pain
±
tingling
at
the
access
site
Numbness
±
weakness
at
access
site
or
down
the
leg
Decreased
patellar
tendon
reflex
Avoid
injection
or
insertion
lateral
to
the
arterial
pulsation
Physical
therapy
Local
anesthetic
injections
2 Vascular Access

20
Radial Access
Performing cardiac procedures via a TRA compared with a FA is associated with a
reduction in bleeding events and vascular complications. This is largely driven by
lower rates of minor bleeding [10]. A shift to a “radial-first” strategy in the United
States has improved acute coronary syndrome related outcomes, quality of life met-
rics, and reduced healthcare costs [10]. The failure rate for cardiac procedures using
a TRA is higher than the FA and ranges from 1–5% [11].
TRA Failure
• TRA failure is usually seen in patients who are:
–
– Short.
–
– Elderly.
–
– Female.
–
– Post-CABG.
• TRA failure is usually attributed to [11]:
–
– The steeper learning curve for obtaining radial access.
–
– The smaller caliber of the radial artery.
–
– Anatomical variations in radial artery distribution.

Advantages and Limitations of TRA for Cardiac Procedures
• Advantages [11]:
–
– Reduced duration of post-procedure bed rest and length of stay.
–
– Lower incidence of access site complications (bleeding, pseudoaneurysm,
and arteriovenous fistulas).
–
– Lower in-hospital mortality.
–
– Patient comfort.
–
– Reduction in overall costs.
• Limitations [11]:
–
– Inability to use larger sheaths (largest recommended is 6–7 Fr sheath).
–
– Increased radiation exposure (exposure is greater with the right TRA com-
pared with a left TRA; overall exposure decreases with experience).
–
– Potential for radial spasm, radial artery occlusion, other vascular complica-
tions (refer to radial complication section below).
–
– Potential need for crossover to a FA.

21

Vascular Anatomy of the Hand
• The ulnar artery and the radial artery provide a dual blood supply to the hand
(Fig. 2.3).
• The superficial palmar arch lies below the palmar fascia. It is supplied predomi-
nantly by the ulnar artery and to a lesser degree by the superficial branch of the
radial artery.
• The deep palmar arch lies beneath the flexor tendons and proximal to the super-
ficial arch. It is supplied predominantly by the deep branch of the radial artery
and to a lesser degree by the deep branch of the ulnar artery.
• Patients may have variations in anatomy limiting or precluding dual blood sup-
ply to the hand. If this is the case, a TRA should be avoided.
• Allen’s test or Barbeau’s test can help evaluate the presence of adequate blood
supply to the hand before performing a procedure via the TRA.
Radial artery
Superficial branch
of radial artery
Deep palmar
artery
Ulnar artery
Deep branch
of ulnar artery
Superficial
palmar arch
Fig. 2.3 Arterial supply
of the hand
2 Vascular Access

22

Patient Screening and Selection
• TRA is preferred in patients who are at high risk for femoral vascular access
complications. These patients include:
–
– Morbid obesity (125 kg).
–
– Severe lower extremity peripheral vascular disease.
–
– Abdominal aortic aneurysm with thrombus.
–
– Anticoagulated patients.
–
– Patients who cannot lie flat.
–
– Patients with bleeding diathesis.

Contraindications for Radial Access
• Non-palpable radial artery pulse.
• INR 2.5 for elective procedures.
• Patients with existent AV fistula for dialysis or those at risk for starting dialy-
sis [10].
• Severe vaso-occlusive disease (i.e. Raynaud disease, Takayasu arteritis, throm-
boangiitis obliterans) [10].
• Documented small radial artery size or known complex radial/brachiocephalic
anatomy [10].
Preprocedural Testing
• Adequate collateral circulation to the hand can be assessed by performingAllen’s
test or the Barbeau’s test (more objective) [2].
–
– Neither test has been shown to predict clinically significant periprocedural
complications and performing these tests is not mandatory.
• The most reliable method to assess collateral circulation is by using Doppler
ultrasonography [2].
–
– Allows for evaluation of the blood flow in the arteries and collaterals.
–
– Allows for a better understanding of vascular anatomy.
Allen’s Test
• The patient is asked to make a fist.
• The operator simultaneously compresses the radial and ulnar arteries, occluding
both arteries (Fig. 2.4).
Pearl
• Left TRA is preferred in patients of short stature, older age, with a high
probability of tortuosity in the right subclavian artery, and those requiring
LIMA angiography.

23
• The patient opens and closes their hand five times. The final opened palm should
appear blanched.
• Pressure on the ulnar artery is released while maintaining occlusive pressure on
the radial artery. The hand is observed for color changes.
–
– Return of the hand color to pink within 8–10 s is a “positive” Allen’s test and
suggests that the ulnar blood supply in that hand will be sufficient if the radial
artery is occluded (Fig. 2.5).
–
– If the release of the ulnar artery occlusive pressure does not result in a return
of pink hand color within 8–10 s then it is a ‘negative’ Allen’s test. This sug-
gests that the ulnar blood supply to the hand will be insufficient if the radial
artery is occluded. TRA on that hand should be avoided, and alternative access
should be obtained.
Fig. 2.4 Allen’s test,
compress the radial and
ulnar arteries
simultaneously
Fig. 2.5 Release the
ulnar artery
2 Vascular Access

24
Barbeau’s Test (Allen’s Oximetry Test)
• Attach a pulse oximeter to the access site hand and observe the pulse waveform
on plethysmography.
• Apply occlusive pressure to both the radial and ulnar arteries simultaneously so
the waveform on plethysmography is absent.
• Release pressure from the ulnar artery while maintaining occlusive pressure on
the radial artery, monitor the pulse waveform on plethysmography, and compare
findings with baseline pulse waveform on plethysmography (Fig. 2.6).
• Changes of the tracing are classified by the Barbeau classification into four cat-
egories (Fig. 2.7).
Type
A
B
C
D
Precompression Radial artery compression
Start
Oximetry
+
+
+
+
–
–
+
–
Oximetry
After 2 min
Fig. 2.7 Barbeau test
Fig. 2.6 Compress the
radial artery and ulnar
artery to occlude both
vessels until the waveform
on plethysmography is
absent, release the ulnar
artery, and observe the
pulse waveform of the
ulnar artery

25
–
– Type A: no change in pulse wave.
–
– Type B: damped but distinct pulse waveform.
–
– Type C: loss of phasic pulse waveform, followed by recovery in 2 min.
–
– Type D: no recovery of pulse tracing within 2 min.
• Interpretation of the Barbeau’s test findings.
–
– Normal test:
Return of a waveform (Type A waveform).
–
– Abnormal test if any of the following:
Oximetry readings are different after the release of ulnar artery occlusive
pressure (Type B or C waveform).
Continued absence of a waveform (Type D waveform) (Do not cannulate
the radial artery if a type D waveform is present).
Prepping the Arm
• The arm is immobilized on the radial arm board with the palm facing upward and
obliquely.
• The wrist is hyperextended with a wrist brace or towels. In this position, the
radial artery is more superficial, making it easier to palpate (Fig. 2.8a).
• A pulse oximeter is placed on the index finger for continuous monitoring during
the procedure.
• Sterilizing solution is applied to the area from the flexor crease to the mid-
forearm. Also, prepare and sterilize the right and left groin because of the possi-
bility of cross-over from the TRA, or the need for mechanical support.
• Drape the arm and hand so only the area from the styloid process of the radius to
approximately 5 cm proximal is exposed.

Radial Artery Puncture and Sheath Insertion
• Pre-procedure planning is crucial for TRA success. It helps avoid multiple arte-
rial punctures, reduces the risk of radial artery spasm, and vascular
complications.
• Ultrasound can be used to visually identify radial artery location, depth, course,
and patency.
• Palpate the radial artery, stabilize it with the tip of your finger, and apply local
skin anesthesia with 0.5–1 ml 1% lidocaine.
• The radial artery puncture site should be 2 cm proximal to the styloid process
(Fig. 2.8b).
• Use one of two techniques to gain successful radial artery access.
–
– Seldinger technique with back wall puncture (Double-wall ‘Through-and-
Through’approach).
2 Vascular Access

26
b
d e
f g
c
a
Fig. 2.8 Steps of radial access. (a) Hyper-extend the wrist. (b) Puncture 2 cm above the styloid
process. (c) Pulsatile blood flow is seen. (d) Advance needle a few millimeters. (e) Thread the
0.018” guidewire through the needle. (f) Remove the needle. (g) Insert the Terumo sheath

27
When blood appears in the hub of the IV catheter (Fig. 2.8c), the needle
and catheter system is advanced a few millimeters through the back wall of
the artery to transfix the artery.
Subsequently, the needle is withdrawn leaving the catheter in place
(Fig. 2.8d).
The catheter is gently drawn back until pulsatile backflow appears.
Once pulsatile blood flow is observed, advance a 0.018˝ nitinol floppy
guidewire (30–50 cm in length, with a floppy tip and more rigid shaft)
through the cannula of the catheter (Fig. 2.8e).
Once the wire is passed to the desired level through the cannula, the cath-
eter is removed leaving the wire in place (Fig. 2.8f).
–
– Single-wall anterior puncture technique.
This approach uses a 21-gauge micropuncture needle that is 2–5 cm
in length.
You may or may not feel a tactile “pop” as the needle passes through the
anterior wall of the radial artery.
When the needle is in the lumen, you will have immediate brisk blood
flow, which may not necessarily be pulsatile.
Once you have steady blood flow insert a 0.018″ nitinol floppy guidewire,
remove the needle, and leave the guidewire in place.
• Advance a 10 cm hydrophilic sheath over the 0.018″ nitinol floppy guidewire
(Fig. 2.8g).
–
– Sheath size is selected based on the minimum inner diameter needed to
accommodate the equipment to be used for the procedure.
–
– To reduce radial artery occlusion, try to maintain a radial artery inner diame-
ter to sheath outer diameter ratio of 1.10.
–
– For most patients, a 6 Fr sheath is generally safe to use and preferred (should
interventionberequired,thesheathdoesnotnecessarilyneedtobeexchanged).
• Remove the guidewire and dilator, and leave the sheath within the artery.
• Next, a cocktail consisting of an antithrombotic agent (unfractionated heparin,
enoxaparin, or bivalirudin), and one or more vasodilators (nitroglycerin, vera-
pamil, and nicardipine) is prepared in a single 50 cc syringe and given through
the sheath sidearm to prevent thrombosis and vasospasm.
–
– When giving the cocktail aspirate 20–30 cc of blood to dilute the mixture
before injection and deliver the cocktail slowly over 30–60 s, as this helps
reduce patient discomfort.
• After delivery of the cocktail, flush the sheath with 10 cc of heparinized saline.
• Secure the sheath in place with a transparent adhesive dressing.
Antithrombotic Agents
• The recommended doses of antithrombotic agents are as follows [2]:
2 Vascular Access

28
–
– Unfractionated heparin 50 IU/kg, up to 5000 IU total.
–
– Enoxaparin 60 mg.
–
– Bivalirudin 0.75 mg/kg bolus intravenously for diagnostic procedures, fol-
lowed by infusion at 1.75 mg/kg/h if PCI is indicated.
Vasodilators Agents
• The recommended doses of vasodilator agents are as follows [1]:
–
– Verapamil 2.5 mg; Verapamil is to be used cautiously (or avoided entirely) if
the patient has severely reduced systolic left ventricular function or
bradycardia.
–
– Nitroglycerin 200μg; Nitroglycerin is to be avoided in hypotensive patients or
those with severe aortic stenosis.
Radial Complications

Radial Artery Spasm
• Most common reason for TRA failure (~40% of cases) [13].
• Risk factors predisposing for spasm:
–
– Younger age.
–
– Women.
–
– Lower body weight.
–
– Small radial artery diameter.
–
– Large sheath size.
–
– Multiple access attempts.
–
– Number of catheters used.
–
– Procedure duration.
Pearls
• When using the Seldinger technique with back wall puncture, ascertaining
pulsatile flow from the IV catheter is essential before proceeding. Pulsatile
flow may not be seen when using a micropuncture needle.
• Quickly recognize problems by tactile feedback from a floppy tipped
guidewire. If you feel resistance while advancing the 0.018″ nitinol floppy
guidewire, stop, and perform the following steps to delineate the level and
type of impedance encountered [12].
–
– Fix the guidewire and remove the IV catheter.
–
– Partially insert a 5 Fr or 6 Fr sheath dilator into the artery over the
guidewire to a distance of 5–10 cm and remove the guidewire.
–
– Perform angiography using 3–5 cc of contrast.

29
• Suspect spasm if the patient reports pain in the arm or if there is resistance to
catheter advancement.
• Angiographically the vessel will appear narrowed with smooth arterial contours.
• Differential diagnosis must include inadvertent recurrent radial artery access,
anomalous radial origin (high origin) and course, medial calcific sclerosis
(Mönckeberg disease).
• Prevention and Treatment [12]:
–
– Gaining radial access on the first attempt is imperative because the vessel is
prone to spasm with repeated attempts.
–
– Medications:
Give additional sedation.
Direct administration of vasodilatory/antispasmodic agents through the
sidearm of the introducing sheath (nitroglycerin, verapamil, diltiazem,
adenosine, nitroprusside, or nitric oxide).
–
– Repeat angiography after several minutes to assess if the spasm has resolved
If spasm resolves, use a 0.035″ wire to traverse the area of spasm. If the wire
passes, then load and advance the catheter over the wire.
If spasm does not resolve, consider using alternative access.

Radial Artery Occlusion
• Most common complication following TRA (typically subclinical).
• Occurs usually shortly after the procedure (~1–10% of cases) [2]:
• Concerning because [2]:
–
– Increased risk of developing hand ischemia.
–
– Unable to use a TRA for future procedures.
–
– Radial artery is no longer a suitable conduit for:
Coronary artery bypass grafting.
Arteriovenous fistula formation for patients requiring dialysis access.
Intra-arterial pressure monitoring.
• Risk factors predisposing for RAO [2]:
–
– Older age.
–
– Women.
–
– Lower body weight.
–
– Elevated creatinine.
–
– Peripheral artery disease.
–
– Diabetes.
–
– Smoking.
• Procedural factors associated with RAO [2]:
–
– Sheath size relative to the radial artery diameter.
Larger sheaths increase the risk of vascular trauma and create a prothrom-
botic state.
It is important to maintain a sheath-to-artery diameter ratio 1.10.
–
– Inadequate anticoagulation.
2 Vascular Access

30
–
– Inadequate patent hemostasis.
• Majority of patients are asymptomatic because of dual blood supply and exten-
sive collateral circulation involving the hand.
• Suspect RAO if the radial pulse is absent.
–
– However, the presence of a radial pulse does not exclude the diagnosis of
RAO because there may be collateral blood supply to the area around the RAO.
• Patency is best assessed clinically using the reverse Barbeau’s test or
Doppler US [2].
–
– Reverse Barbeau’s test: pulse oximeter is placed on the thumb or 1st digit of
the ipsilateral hand, and then the ulnar artery is occluded. If the plethysmog-
raphy waveform is absent, this highly suggests RAO.
–
– Doppler US: allows for direct imaging of the artery and assessment of blood
flow within the vessel. If visible obstruction or absent blood flow, it is diag-
nostic of RAO.
• Prevention and treatment [2]:
–
– Spontaneous recanalization occurs within 1–3 months in 50% of patients.
–
– Smaller and appropriately sized sheaths should be used, and upgraded to a
larger sheath when required.
–
– Consider using sheath-less guide catheters. These catheters reduce the outer
diameter of the vascular access system by 1–2 Fr compared with conventional
sheaths and catheters.
–
– Administer adequate anticoagulation as part of the initial cocktail.
–
– Consider administration of unfractionated heparin 50 IU/kg, up to 5000 IU
total at the end of the case [14].
–
– Initial treatment is usually conservative:
Begin with compression of the ipsilateral ulnar artery for an extended
period (up to 60 min).
If the above method fails, most cases of RAO can be managed with enoxa-
parin or fondaparinux for 4 weeks duration.
If this fails, percutaneous recanalization can be considered.
In rare cases, acute treatment and emergent vascular surgery consultation
may be required (i.e. acute ischemia of the hand).

Access Site Hematoma
• Generally results from improper hemostatic device application or device failure.
• Usually, it is easily managed with compression of the radial artery by placing a
vascular band in the correct position.
–
– The radial artery should be compressed proximal and distal to the puncture
site to control antegrade and retrograde flow.
Forearm Hematoma
• Occurs in 0.3% of cases [13].

31
• Early recognition of this complication is of critical importance because bleeding
may already be significant before it even manifests with forearm swelling.
• Management and treatment [13]:
–
– Crucial to rapidly assess and treat this complication.
–
– If not controlled and managed appropriately, a trivial forearm hematoma can
develop into a serious compartment syndrome.
–
– Immediately palpate the forearm, compare findings of softness and size with
the opposite arm.
–
– Apply hemostatic compression along the length of the access artery to prevent
further blood extravasation.
Application of an Ace bandage to the forearm.
Application of an Ace bandage with gauze balls placed along the course of
the artery. Tightening the ace bandage over the gauze balls selectively
compresses the artery.
Use a sphygmomanometer cuff to compress the brachial artery.
• Inflate the cuff to a pressure 10–20 mmHg more than systolic
blood pressure, and then intermittently deflate it every 2–3 min for
10–15 s. Repeat this cycle until adequate hemostasis is achieved.
Sealing of the perforation with a long sheath (rarely necessary).
• If a perforation occurs before angioplasty, one can continue to use a
guiding catheter and complete the procedure, by which time the per-
foration usually seals off.
• Sealing of the perforation with a covered stent (rarely necessary)
• If the patient develops pain, pallor, paresthesia, paralysis, or absent pulse suspect
compartment syndrome.
–
– Direct measurement of the compartment pressure is a useful confirmatory
tool and helps guide treatment strategy (conservative vs. urgent surgical
fasciotomy).
Pseudoaneurysm Formation
• Rarely occurs with TRA.
• Antecedent oral anticoagulation is the biggest risk factor.
• Usually managed with prolonged compression for 10–20 min.
• If pseudoaneurysm fails to occlude with compression, surgery may be required.
–
– This can be performed using local anesthesia, and done as an outpatient.

Radial Artery Tortuosity or Loop
• Tortuosity occurs in 10% of cases [12].
• Loops occur in 1% of cases [12].
• Treatment:
–
– Perform angiography to help define anatomy if there is difficulty advancing
a 0.035″ guidewire.
2 Vascular Access

32
Position the access sheath appropriately.
Perform arteriogram using 3–5 cc of contrast.
–
– Use an angle-tip hydrophilic-coated wire with catheter support, and advance
it using fluoroscopy.
Hydrophilic wires allow for smooth, rapid movement through a tortuous
segment of a vessel. However, they are highly prone to navigate into small
side branch vessels and should be advanced using fluoroscopy.
–
– If the above technique fails to navigate the loop, use a 0.014″ coronary wire.
Occasionally, you might need to use two coronary wires to assist with the
tracking of the catheter.
–
– If the above technique fails to navigate the loop, use a 2.0–2.5/12 mm balloon
to perform balloon-assisted tracking of the catheter.
Remember to position the balloon so half of its length protrudes outside
the tip of the catheter and insufflate to low pressure (4 atm).
–
– If the catheter navigates the loop, exchange the wire to a stiff angle glidewire
and reduce the loop with traction and counterclockwise rotation of the cathe-
ter and wire.

Radial Artery Stenosis
• Very rare.
• If the stenosis is focal and equipment can easily traverse the lesion, then it is
reasonable to continue with the procedure, otherwise, alternative access should
be pursued [12].

Other Rare Complications
• List of other potential transradial access site complications [2, 13]:
–
– Radial arteriovenous fistula formation.
–
– Radial artery eversion during sheath removal.
–
– Hand ischemia.
–
– Compartment syndrome.
–
– Radial artery avulsion due to intense spasm.
–
– Sterile abscess formation at the radial artery access site.
–
– Persistent post-procedural pain.
–
– Upper extremity loss of strength.
Pearl
• Patients should be well sedated before performing the procedure.
• If the catheter fails to advance despite the techniques described above,
obtain alternative access.

33
References
1. Patel A, Naides AI, Patel R, Fischman A. Transradial intervention: basics. J Vasc Interv Radiol
2015 May;26(5):722. https://doi.org/10.1016/j.jvir.2015.01.021. PubMed PMID: 25921454.
2. Avdikos G, Karatasakis A, Tsoumeleas A, Lazaris E, Ziakas A, Koutouzis M. Radial
artery occlusion after transradial coronary catheterization. Cardiovasc Diagn Ther. 2017
Jun;7(3):305–316. https://doi.org/10.21037/cdt.2017.03.14. Review. PubMed PMID:
28567356; PubMed Central PMCID: PMC5440258.
3. Fenger-Eriksen C, Münster AM, Grove EL. New oral anticoagulants: clinical indica-
tions, monitoring and treatment of acute bleeding complications. Acta Anaesthesiol Scand
2014;58:651–659. PMID: 24716468.
4. Ahmed B, Lischke S, Holterman LA, Straight F, Dauerman HL. Angiographic predictors of
vascular complications among women undergoing cardiac catheterization and intervention. J
Invasive Cardiol 2010;22:512–516. PMID: 21041845.
5. Seto AH, Abu-Fadel MS, Sparling JM, et al. Real-time ultrasound guidance facilitates femo-
ral arterial access and reduces vascular complications: FAUST (Femoral Arterial Access with
Ultrasound Trial). JACC Cardiovasc Interv. 2010;3:751–8.
6. Garrett PD, Eckart RE, Bauch TD, Thompson CM, Stajduhar KC. Fluoroscopic localization of
the femoral head as a landmark for common femoral artery cannulation. Catheter Cardiovasc
Interv 2005;65:205–207. PMID:15900552.
7. Spijkerboer AM, Scholten FG, Mali WP, van Schaik JP. Antegrade puncture of the femoral
artery: morphologic study. Radiology 1990;176:57–60. PMID:2353111.
8. Grier D, Hartnell G. Percutaneous femoral artery puncture: practice and anatomy. Br J Radiol
1990;63:602–604. PMID: 2400874.
9. Lechner G, Jantsch H, Waneck R, Kretschmer G. The relationship between the common femo-
ral artery, the inguinal crease, and the inguinal ligament: a guide to accurate angiographic
puncture. Cardiovasc Interv Radiol 1988;11:165–169. PMID: 3139299.
10. Mason PJ, Shah B, Tamis-Holland JE, et al. An update on radial artery access and best prac-
tices for transradial coronary angiography and intervention in acute coronary syndrome: a
scientific statement from the American Heart Association. Circ Cardiovasc Interv. 2018
Sep;11(9):e000035. https://doi.org/10.1161/HCV.0000000000000035. PubMed PMID:
30354598.
11. Gupta S, Nathan S, Perlowski A. Basics of radial artery access. Cardiac Interventions Today.
2013 July/August: 25–31.
12. Esente P, Giambartolomei A, Simons AJ, Levy C, Caputo RP. Overcoming vascular ana-
tomic challenges to cardiac catheterization by the radial artery approach: specific techniques
to improve success. Catheter Cardiovasc Interv 2002 Jun;56(2):207–211. PubMed PMID:
12112914.
13. Chugh SK, ChughY, Chugh S. How to tackle complications in radial procedures: tip and tricks.
Indian Heart J 2015 May–Jun;67(3):275–281. https://doi.org/10.1016/j.ihj.2015.05.016. Epub
2015 Jun 16. Review. PubMed PMID: 26138190; PubMed Central PMCID: PMC4495672.
14. Hahalis GN, Leopoulou M, Tsigkas G, Xanthopoulou I, et al. Multicenter randomized evalua-
tion of high versus standard heparin dose on incident radial arterial occlusion after transradial
coronary angiography: the SPIRIT of ARTEMIS Study. JACC Cardiovasc Interv. 2018 Nov
26;11(22):2241–2250. https://doi.org/10.1016/j.jcin.2018.08.009. Epub 2018 Nov. PubMed
PMID: 30391389.
2 Vascular Access

35
https://doi.org/10.1007/978-3-030-68538-6_3
Coronary Anatomy and Angiography
Gurpreet S. Johal, Sunny Goel, and Annapoorna Kini
Introduction
The purpose of coronary angiography is to accurately define coronary anatomy, and
obtain optimal angiographic images of the main epicardial coronary arteries and
their branches. It is important to limit radiation exposure to the patient and medical
personnel while trying to obtain the essential number of images to define the anat-
omy, and minimize contrast use. Information obtained from coronary angiography
is significant because it assists in the diagnosis and therapeutic intervention of coro-
nary artery disease. Inadequate knowledge of coronary anatomy and angiographic
views can lead to serious complications, inappropriate interventions, and wasteful
healthcare expenditures.

Coronary Anatomy and Segment Classification
Having a detailed understanding of coronary anatomy is fundamental to perform
coronary angiography safely and efficiently.
• The right and left coronary arteries originate from their respective aortic sinuses,
which are normally located in the upper third of the Sinus of Valsalva. The left
coronary artery (LCA) orifice is superior and posterior relative to the right coro-
nary artery (RCA) orifice [1].
• The LCA begins as the left main coronary artery (LMCA), and bifurcates into
the left anterior descending artery (LAD) and the left circumflex artery (LCx)
(85–90% of cases). Occasionally, the LCA trifurcates giving rise to an additional
artery called the ramus intermedius (10–15% of cases) [1].
G. S. Johal (*) · S. Goel · A. Kini
e-mail: Gurpreet.Johal@mountsinai.org; Sunny.Goel@mountsinai.org; annapoorna.kini@
mountsinai.org
3

36
• The LAD gives rise to septal perforators and diagonal branches. The LCx gives
rise to obtuse marginal branches, atrial branches, and in a left dominant system
the posterior descending artery (PDA) and posterolateral branches (PLB). The
PDA also gives rise to septal perforators [1].
• The RCA begins and the first branch it gives rise to is the conus artery (50%
cases it arises from a separate ostium). The RCA also gives rise to the sinoatrial
node artery (40–50% of the cases it arises from the LCx), atrioventricular nodal
artery, several smaller marginal branches, and a more prominent acute marginal
branch. The RCA usually gives rise to the PLB and continues as the PDA at the
crux of the heart [1].
• Left or right coronary dominance is based on the artery from which the PDA
arises (Fig. 3.1). Dominance is usually right in 80% of individuals and left in
20% of individuals (left dominance is slightly more frequent in females).
Codominance is no longer used [1].
• We use the sixteen-segment–based coronary segment classification system from
the SYNTAX (Synergy between PCI with Taxus and Cardiac Surgery) score
withslightmodificationtodefinetheindividualcoronarysegments(Table 3.1)[2].
1 5
6
9
9a
9a
10
12
13
15
14
7
8
10a
10
10a
12a
12b
14a
16a
16b
16c
14b
2
3
1 5
6
9
2
3
4
16
11
7
8
12
13
14
12a
12b
14a
14b
11
Left dominant system
a
Right dominant system
b
Fig. 3.1 (a) Left dominant system segment anatomy. (b) Right dominant system segment anat-
omy. (Adapted from Sianos et al. [2])
G. S. Johal et al.

37
Table 3.1 Definition of the coronary tree segments
Segment Name Segment definition
1 RCA proximal From ostium to and including the origin of the first RV
branch.
2 RCA mid RCA immediately distal to the origin of the first RV
branch to the acute margin of the heart.
3 RCA distal From the acute margin of the heart to the origin of the
posterior descending artery.
4 Right posterior
descending
Originating from the distal coronary artery distal to the
crux and running in the posterior interventricular groove.
16 Atrioventrcular
Continuation from RCA
Originating from the distal coronary artery distal to the
crux and running in the atrioventricular groove.
16a Posterolateral from RCA First posterolateral branch from segment 16.
16b Posterolateral from RCA Second posterolateral branch from segment 16.
16c Posterolateral from RCA Third posterolateral branch from segment 16.
5 Left main From the ostium of the LCA through bifurcation into left
anterior descending and left circumflex branches.
6 LAD proximal Proximal to and including the first major septal branch.
7 LAD mid LAD immediately distal to the origin of the first septal
branch and extending to the point where LAD forms an
angle (RAO view). If this angle is not identifiable, this
segment ends at one-half the distance from the first septal
to the apex of the heart, usually after two diagonal
branches have originated.
8 LAD distal Terminal portion of LAD, beginning at the end of the mid
segment and extending to or beyond the apex.
9 First diagonal The first diagonal originating from segment 6 or 7.
9a First diagonal a Additional first diagonal originating from segment 6 or 7,
before segment 8.
10 Second diagonal Second diagonal originating from segment 8 or the
transition between segments 7 and 8.
10a Second diagonal a Additional second diagonal originating from segment 8.
11 Proximal circumflex Main stem of circumflex from its origin of left main to
and including the origin of the first obtuse marginal
branch.
12 Ramus intermedius Branch from trifurcating left main other than proximal
LAD or LCX. Belongs to the circumflex territory.
12a Obtuse marginal a First side branch of circumflex running in general to the
area of the obtuse margin of the heart (down and out in
RAO view)
12b Obtuse marginal b Second additional branch of circumflex running in the
same direction as 12.
13 Distal circumflex The stem of the circumflex distal to the origin of the most
distal obtuse marginal branch and running along the
posterior left atrioventricular grooves. Caliber may be
small or artery absent.
14 Left posterolateral Running to the posterolateral surface of the left ventricle
(horizontal and down in RAO view). May be absent or a
division of obtuse marginal branch.
14a Left posterolateral a Distal from 14 and running in the same direction.
14b Left posterolateral b Distal from 14, and 14a running in the same direction.
15 Left posterior descending The most distal part of the dominant left circumflex when
present. Gives origin to septal branches. When this artery
is present, segment 4 is usually absent
Adapted from Sianos et al. [2]
3 Coronary Anatomy and Angiography

38
Imaging Basics
When performing coronary angiography, it is necessary to obtain multiple views in
different orthogonal planes to clearly define all vessel segments [3].
Image Orientation
• The orientation of the angiographic image is defined by the position of the imag-
ing detector relative to the patient (not the X-ray tube). It is described using two
angles from the center of the patient (Fig. 3.2) [4].
–
– The first angle refers to ‘rotation’. It describes the position of the image inten-
sifier along the transverse (axial) plane of the patient. It is referred to as
degrees right anterior oblique (RAO) (to the patient’s right) or left anterior
oblique (LAO) (to the patient’s left).
–
– The second angle refers to ‘angulation’. It describes the position of the image
intensifier along the sagittal plane of the patient. It is referred to as degrees cra-
nial (towards the head of the patient) or caudal (towards the feet of the patient).
• All views are reported by convention with left or right rotation first, followed by
the cranial or caudal angulation [3].
Antero posterior
axis
Lateral axis
Longitudinal axis
θ
φ
Sagittal
plane
Coronal
plane
Transverse plane
Central
ray
Fig. 3.2 Nomenclature of axes and planes relative to the patient. (Adapted fromAldridge et al. [4])
G. S. Johal et al.

39
• When the image intensifier is vertically above the patent without any rotation or
angulation it is referred to as antero-posterior (AP).
• When the image intensifier is angled at 90° and parallel to the floor it is referred
to as either the left or the right lateral projection, depending on the position of the
image intensifier relative to the patient.
Image Projections
• All major coronary arteries lie in one of two planes, the interventricular septum
or the AV groove (Fig. 3.3). The recommended image projections are intended to
display the coronary artery and anatomy along these planes [3].

Our Protocol for Coronary Angiography
In most cases, for a right dominant system, the LCA can be adequately visualized
using three views (LAO Caudal, RAO Caudal, and RAO Cranial), and the RCA in
two views (LAO and LAO Cranial).
L MAIN
L MAIN
LAO 60
RAO 30
OM D
D
D
D
D
D
LAD
LAD
RCA
RCA
S
S
S
S
PL
PL
PD
PD
OM
OM
OM
SN
SN
RV
RV
AcM
AcM
CX
CX
CB
CB
L MAIN
L MAIN
L MAIN
D
D
D
D
D
LAD
LAD
RCA
RCA
S
S
S
S
PL
PL
PD
PD
OM
OM
OM
SN
RV
RV
AcM
AcM
CX
CX
CX
CX
CB
CB
Atrioventricular
plane
Atrioventricular
plane
Interventricular
plane
Fig. 3.3 Representation of coronary anatomy in relation to the interventricular and atrioventricu-
lar valve planes as seen in two views: right anterior oblique (RAO) and left anterior oblique (LAO).
Coronary branches are as follows: AcM, acute marginal; CB, conus branch; CX, circumflex; D,
diagonal; L Main, left main; LAD, left anterior descending; OM, obtuse marginal; PD, posterior
descending; PL, posterolateral left ventricular; RCA, right coronary; RV, right ventricular; S, sep-
tal; SN, sinus node. (Adapted from Grossman’s cardiac catheterization, angiography, and inter-
vention. 6th edition [3])

40
For a left dominant system, the LCA can be adequately visualized using four
views (LAO Caudal, RAO Caudal, RAO Cranial, and LAO Cranial), and the RCA
in one view (LAO).
Further specifics regarding the usual degree of angulation are detailed below.
The degrees of rotation and angulation are general guidelines, and an operator must
always take into account patient-specific details such as body habitus, patient rota-
tion, coronary anatomy, and heart orientation.

Left Coronary System
• The following views help optimize specific segments of the LCA. However, no
single view is exclusive and the vessel should be seen in its entirety. The follow-
ing degrees of rotation and angulation are suggestions and need to be optimized
for each patient on a case-by-case basis.
–
– LAO Caudal [40°, 40°]:
LM
Proximal LAD.
Proximal LCx and OM’s
–
– LAO Cranial [30°, 30°]:
Mid and distal LAD.
Separates the septal from the diagonal branches.
Distal LCx and LPDA in a left dominant system.
–
– AP Caudal [0°, 30°]:
Distal LM bifurcation (or short LM).
Proximal LAD.
Proximal to mid-LCx and OM’s.
–
– AP Cranial [0°, 30°]:
Proximal and mid LAD.
–
– RAO Caudal [25°, 25°]:
LM bifurcation.
Proximal LAD.
Proximal to mid-LCx.
–
– RAO Cranial [30°, 40°]:
Mid and distal LAD.
Distal LCx, LPL branches, and LPDA (if a left dominant system).
G. S. Johal et al.

41

Right Coronary System
• The following views help optimize specific segments of the RCA. However, no
single view is exclusive and the vessel should be seen in its entirety. The follow-
ing degrees of rotation and angulation are suggestions and need to be optimized
for each patient on a case-by-case basis.
–
– LAO [30°, 0°]:
Ostial and proximal RCA.
–
– AP Cranial [0°, 30°]:
Distal RCA bifurcation, RPDA and RPL branches.
–
– RAO [30°, 0°].
Mid-RCA and mid RPDA.

Defining Specific Lesions
• We use the following views to better visualize specific lesions:
• Native Vessel
–
– LM:
Ostial: RAO cranial, AP cranial, LAO cranial.
Body: RAO caudal, AP caudal, LAO caudal.
–
– LAD:
Ostial/proximal: LAO caudal, LAO cranial.
Mid/distal: AP cranial, RAO cranial.
–
– Diagonals:
Origin: LAO cranial, LAO caudal.
–
– Septals:
RAO cranial, AP cranial.
–
– Ramus:
Ostial/proximal: spider, AP caudal.
Distal: AP caudal.
–
– Circumflex:
Ostial/proximal: spider, AP caudal.

42
–
– OMs:
Ostial/proximal: RAO caudal.
LPDA: LAO cranial, AP cranial.
–
– RCA:
Ostial/proximal: LAO caudal.
Mid: RAO 30°.
Distal: AP cranial/RAO cranial/LAO cranial.
–
– RPDA/RPL Branches:
AP cranial/RAO cranial.
Early bifurcating RPDA: RAO 30°.
• Grafts
–
– LIMA:
Ostium/body: AP straight [0°, 0°].
Anastomosis to LAD: RAO 30°, or AP cranial.
LAD after anastomosis: AP cranial.
–
– RIMA:
Ostium/body: AP straight [0°, 0°].
Anastomosis and native vessel after anastomosis: depends on vessel
bypassed (see above).
–
– SVG:
Ostium/body: LAO 30°, or RAO 30°.
Anastomosis to RCA/PDA/PL: LAO cranial, RAO, AP cranial.
Anastomosis to LCX/OM/Ramus: RAO caudal, LAO caudal.
Anastomosis to LAD/Diagonal: AP cranial, RAO cranial, LAO cranial,
AP, lateral (the lateral view is especially useful to visualize anastomosis
to LAD).
Anastomosis and native vessel after anastomosis: depends on the vessel
bypassed (see above).
• Collaterals
–
– Left to right:
LAO cranial.
–
– Right to left:
RAO straight.
G. S. Johal et al.

43
Left Ventricle Angiography
Angiography of the left ventricle (LV) helps with the evaluation of LV function,
segmental wall motion, mitral regurgitation, ventricular septal defects, hypertrophic
cardiomyopathy, and intraventricular thrombus.
Setup
• It is best performed using a pigtail catheter with the catheter placed in the mid
LV cavity, and not entangled with the mitral valvular apparatus.
• Power injector setup:
–
– Extreme care must be taken to assure no air is within the system (prevent air
embolism).
–
– Synchronize the timing of the injection with the R wave (prevent R on T
phenomenon).
–
– Power injector settings: 40 cc of contrast, 15 cc/s flow, 650 PSI, 0.2 s rise.
If the LV cavity is large or high cardiac output, then you can increase the
volume and rate.
If the LV cavity is small or there is LV outflow obstruction/aortic stenosis,
then you should decrease the volume and rate.
• When injecting, the catheter should be held close to the sheath to avoid migra-
tion, ectopy, or catheter blow-back into the aorta.
• Panning of the table may be required (usually pushing the table away from the
operator—standing on the patient’s right) to visualize regurgitation into the left
atrium (particularly if the atrium is dilated).
• In patients with markedly elevated LVEDP (20 mmHg), consider administrating
intracavitary nitroglycerin (200 mcg) to reduce filling pressures, and repeat LV
angiography (if there are no contraindications and clinically appropriate).
LV Imaging
• RAO 30°:
–
– Anterobasal, anterolateral, apical, inferior, and posterobasal wall segments
(Fig. 3.4).
–
– Mitral regurgitation.
• LAO 45–60°:
–
– Posterolateral, lateral, and septal wall segments (Fig. 3.4).
–
– Ventricular septal defect.

44

Quantification of Aortic and Mitral Regurgitation (Table 3.2)
RAO
LAO
LA
LA
10.
Superior
lateral
LV
LV
LA
LV
LV
1. Anterobasal
2. Anterolateral
5.
Posterobasal 4.
Diaphragmatic
6.
Basal septal
7.
Apical septal
3.
Apical
9.
Inferior
lateral
8. Posterolateral
Fig. 3.4 Diagrammatic representation of RAO and LAO views of the LV obtained during contrast
angiography showing division of the LV wall into 10 numbered segments. LA indicates left atrium;
LAO = left anterior oblique; RAO = right anterior oblique. (Adapted from Hendel et al. [5])
Table 3.2 Angiographic grades of aortic and mitral regurgitation
Grade Aortic regurgitation Mitral regurgitation
1+ Contrast refluxes from the aortic root into
the left ventricle but clears on each beat,
and does not outline the left ventricle
Contrast refluxes into the left atrium but
clears on each beat, and does not outline
the left atrium
2+ Contrast refluxes into the left ventricle
with a gradually increasing density of
contrast in the left ventricle that never
equals contrast intensity in the aortic root,
and outlines the left ventricle
Left atrial contrast density gradually
increases but never equals left ventricle
density, and outlines the left atrium
3+ Contrast refluxes into the left ventricle
with a gradually increasing density;
the left ventricle and aortic root density are
equal after several beats
The density of contrast in the atrium and
ventricle equalizes after several beats
4+ Contrast fills the left ventricle resulting in
an equivalent radiographic density in the
left ventricle and aortic root on the first
beat, and persists for at least 3 beats
The left atrium becomes as dense as the
left ventricle on the first beat, and contrast
is seen refluxing into the pulmonary veins
Adapted from Apostolakis et al. [6]
G. S. Johal et al.

45
Angiography Interpretation
A systematic interpretation of a coronary angiogram involves careful lesion quanti-
fication in at least 2–3 orthogonal views of the left coronary system, and 1–2 orthog-
onal views (depending on dominance) of the right coronary system.
In addition, to assessing coronary artery lesion stenosis, other characteristics of
the vessel and lesion must be addressed (Table 3.3) [7].
Table 3.3 Angiographic description and parameters for lesion quantification
Coronary vessel size Diameter of vessel
Small 2.0 mm
Moderate 2.0–3.0 mm
Large 3.0 mm
Eccentricity of lesion Lesions location description
Concentric Circumferential
Eccentric
Type 1
Type 2
Lesion is located to one side of a vessel
Smooth and broad neck
Irregular surface and/or narrow neck
Complex With multiple irregularities
Ostial lesion types Vessels involved (originate within 3 mm of an originating
vessel)
Aorto-ostial LM, RCA, SVGs, free LIMA, free RIMA (also considered
pedicle LIMA and RIMA even though they arise from
subclavian arteries)
Non-aorto-ostial LAD, LCx, RI
Branch ostial Septals, Diagonals, OMs, PDA, AV continuation, RPLs
Calcification severity Calcification severity description
None No radiopacity
Mild Faint radiopacities noted during cardiac cycles
Moderate Dense radiopacities noted during the cardiac cycle before
contrast injection
Severe Dense radiopacities noted on both sides of the arterial wall
“tram-track” without cardiac motion before contrast injection
Stenosis types Description of types of stenosis/length of stenosis
Focal (discrete) 10 mm
Tubular 10–20 mm
Diffuse (long) 20 mm
Tandem Two lesions close to one another with a normal segment in
between but require two separate stents to cover
Sequential Two lesions close to one another with a normal segment in
between but can be covered by a single stent
Myocardial blush grade Myocardial blush grade description
0 No or minimal blush
1 Stain present, blush persists on next injection
2 Dye strongly persistent at end of washout; gone by next
injection
3 Normal ground glass appearance of blush; dye mildly persistent
at end of washout
(continued)

46
Table 3.3 (continued)
TIMI grade TIMI grade description
0 No anterograde flow beyond the point of occlusion (no flow).
1 Contrast passes the point of obstruction but hangs up and fails
to opacify the entire distal coronary bed during the angiographic
filming sequence (penetration without perfusion)
2 Contrast opacifies the entire coronary bed distal to the stenosis,
but the rate of entry and/or clearance is slower than in
comparable areas not perfused by the distal vessel (partial
perfusion)
3 Complete perfusion. Specifically, the antegrade flow of contrast
with complete filling of the artery and its major and minor
branches within 3 full cardiac cycles. Contrast also clears from
the arterial segment within 3 full cardiac cycles (complete
perfusion)
Thrombus grade Thrombus grade description
0 No thrombus
1 Possible thrombus (mural opacities)
2 Small thrombus (size 0.5 × normal lumen diameter)
3 Medium thrombus (size 0.5–2 × normal lumen diameter)
4 Large thrombus (size 2 × normal lumen diameter)
5 Recent thrombotic occlusion (fresh thrombus with dye stasis
and delayed washout)
6 Chronic total occlusion (smooth, abrupt, and with no dye stasis
and brisk flow)
Rentrop grade Rentrop classification for collateral grading
0 No collaterals (absent)
1 Filling of side branches of a target-occluded epicardial coronary
artery via collaterals without visualization of the epicardial
coronary itself
2 Partial filling of the epicardial segment via collateral arteries
3 Complete filling of the epicardial segment via collateral arteries
G. S. Johal et al.

47

Degree of Tortuosity (Fig. 3.5)

Characteristic of ACC/AHA Type A, B, and C Lesions (Table 3.4)

Bifurcation Lesions Classified Based on Medina Classification
• The most commonly used method to classify bifurcation lesions is the Medina
Classification (Fig. 3.6) [9].
1. No tortuosity: no bend of 45–90% bend prior to lesion.
2. Moderate tortuosity: 1–2 bends of 45–90% prior to the lesion
3. Excessive or severe tortuosity: 3 bends of 45–90% prior to the lesion or 1
or more thane one 90° bend prior to the lesion
LMCA
LCX
LCX
LCX
LCX
LCX
LAD
LAD LAD
LAD
LAD
LMCA LMCA
LMCA
LMCA
OM1
OM1
60°
60°
90°
60°
60°
60°
60°
90° 90°
Fig. 3.5 Description of tortuosity based on severity. (Adapted from Kini et al. [7] with permission
from Elsevier)

48
Table 3.4 ACC/AHA lesion classification
Type A Type B Type C
Discrete (length 10 mm) Tubular (length 10–20 mm) Diffuse (length 20 mm)
Concentric Eccentric –
Readily accessible Moderate tortuosity of the
proximal segment
Excessive tortuosity of the
proximal segment
Non-angulated segment
(45°)
Moderately angulated
(45–90°)
Extremely angulated (90°)
Smooth contour Irregular contour –
Little or no calcification Moderate or heavy
calcification
Degenerated vein grafts with
friable lesions
Absence of thrombus Some thrombus present Significant thrombus present
Non-ostial Ostial location –
No major side branch involved Bifurcation lesion requiring
double guidewires
Inability to protect major side
branch
Less than totally occlusive Total occlusion 3 m Total occlusion 3 months
Adapted from Ryan et al. [8]
1. Main branch proximal lesion 50%: 0 or 1
2. Main branch distal lesion 50%: 0 or 1
3. Side branch lesion 50%: 0 or 1
1,1,1 0,1,1
0,0,1
1,1,0
1,0,0
1,0,1
0,1,0
Fig. 3.6 Medina classification for coronary bifurcation lesions. (Adapted from Latib et al. [9]
with permission from Elsevier)
G. S. Johal et al.

49
• Medina Classification assesses plaque burden based on the presence (1) or
absence (0) of stenosis in the proximal main branch (MB), distal MB, and side
branch (SB).
• A bifurcation lesion is considered significant if it is 50% stenosed, the MB and
SB are within 5 mm of the carina (point of bifurcation), and the SB is 2.5 mm
in diameter.
References
1. Mazur W, Siegel M, Miszawlski-Jamka T, Pelberg R. CT atlas of adult congenital heart disease.
London: Springer Publishing Company; 2013.
2. Sianos G, Morel MA, Kappetein AP, Morice MC, Colombo A, Dawkins K, van den Brand M,
Van Dyck N, Russell ME, Mohr FW, Serruys PW. The SYNTAX score: an angiographic tool
grading the complexity of coronary artery disease. EuroIntervention 2005 Aug;1(2):219–227.
PubMed PMID: 19758907.
3. Baim DS, Grossman W, editors. Grossman’s cardiac catheterization, angiography, and inter-
vention. 6th ed. Philadelphia: Lippincott Williams and Wilkins; 2000.
4. Aldridge HE, McLoughlin MJ, Taylor KW. Special angulated projections in coronary arteri-
ography: a confusion in terminology. Catheter Cardiovasc Diagn 1977;3(4):335–339. PubMed
PMID: 603900.
5. Hendel et al; American Heart Association (AHA). ACC/AHA/ACR/ASE/ASNC/HRS/NASCI/
RSNA/SAIP/SCAI/SCCT/SCMR/SIR 2008 Key data elements and definitions for cardiac
imaging A Report of the American College of Cardiology/American Heart Association Task
Force on Clinical Data Standards (Writing Committee to Develop Clinical Data Standards for
Cardiac Imaging). J Am Coll Cardiol. 2009 Jan 6;53(1):91–124.PubMed PMID: 19118731.
6. Apostolakis EE, Baikoussis NG. Methods of estimation of mitral valve regurgitation for the
cardiac surgeon. J Cardiothorac Surg. 2009 Jul 15;4:34. https://doi.org/10.1186/1749-8090-
4-34. Review. PubMed PMID: 19604402; PubMed Central PMCID:PMC2723095.
7. Kini AS. Coronary angiography, lesion classification, and severity assessment. Cardiol Clin.
2006 May;24(2):153–62, v. Review. PubMed PMID: 16781935.
8. Ryan TJ, Faxon DP, Gunnar RM, Kennedy JW, King SB 3rd, Loop FD, Peterson KL, Reeves
TJ, Williams DO, Winters WL Jr, et al. Guidelines for percutaneous transluminal coronary
angioplasty. A report of the American College of Cardiology/American Heart Association Task
Force onAssessment of Diagnostic and Therapeutic Cardiovascular Procedures (Subcommittee
on Percutaneous Transluminal Coronary Angioplasty). Circulation 1988 Aug;78(2):486–502.
PubMed PMID: 2969312.
9. Latib A, Colombo A. Bifurcation disease: what do we know, what should we do? JACC
Cardiovasc Interv 2008 Jun;1(3):218–226. https://doi.org/10.1016/j.jcin.2007.12.008. PubMed
PMID: 19463303.

Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf

Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf

Recommended

Recommended

More Related Content

What's hot

What's hot (20)

Similar to Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf

Similar to Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf (20)

Recently uploaded

Recently uploaded (20)

Annapoorna Kini,Samin K. Sharma (eds.) - Practical Manual of Interventional Cardiology (2021, Springer International Publishing_ Springer) [10.1007_978-3-030-68538-6] - libgen.li.pdf